6: Biliary tract disease

Question 1

What are two causes of biliary tract disease?

Answer 1

Gall stones

Bile duct cancer

Also: autoimmune disease and infection - seemingly not covered in this lecture

Question 2

What are gallstones?

Answer 2

Solid lumps of crystalised cholesterol or bilirubin formed in the gallbladder

Question 3

Most patients who have gallstones are (symptomatic / asymptomatic).

Answer 3

asymptomatic

Question 4

When the composition of bile is altered, it tends to become static in the biliary tract. What is this called?

What are consequences of this?

Answer 4

Cholestasis

Inflammation and infection

Question 5

What are the three types of gallstone?

Answer 5

Cholesterol

Pigment (bilirubin)

Mixed

Question 6

Gallstones usually form in the gallbladder itself.

Where can they rarely form?

Answer 6

Within the bile duct itself

Question 7

What are the five Fs of gallstones?

Answer 7

Fat

Fertile

Females

Forties

(Fair i.e Caucasian)

Question 8

___ women are at higher risk of developing gallstones.

Answer 8

Pregnant

Question 9

Which inflammatory bowel disease predisposes you to develop gallstones?

Answer 9

Crohn’s disease

Question 10

Why does Crohn’s disease increase your chances of developing gallstones?

Answer 10

Impaired bile salt reabsorption in distal ileum

⇒less recycling of bile salts

⇒altered composition leading to crystalisation

Question 11

Large stones can erode through the wall of the gall bladder into the duodenum - what is this called?

Answer 11

Fistulation

Question 12

Chronic inflammation caused by lodged gallstones causes the walls of the gallbladder to ___.

Answer 12

thicken

Question 13

Gallstones which flow out of the gallbladder may become stuck where?

Answer 13

Cystic duct

Common bile duct

Ampulla of Vater

Ileocaecal valve

Question 14

Biliary colic is a (disease / symptom) associated with gallstones.

Answer 14

symptom

Question 15

Biliary colic is caused by the impaction of a gallstone - where?

Answer 15

Cystic duct

Question 16

Where is pain located in biliary colic?

Where may it radiate?

Answer 16

RUQ

Back / shoulder (referral sites for liver & gallbladder nerves)

Question 17

What symptoms are associated with biliary colic?

Answer 17

Dyspepsia

Nausea

Question 18

Biliary colic pain lasts __ hours and comes on (acutely / gradually).

Answer 18

2-6 hours

gradually

Question 19

What is acute cholecystitis?

What causes it?

Answer 19

Inflammation of the gallbladder

Gallstone in the cystic duct

Question 20

In acute cholecystitis, the gallbladder is initially ___ and then becomes ___.

Answer 20

sterile

infected

Question 21

In acute cholecystitis, the gallbladder becomes distended and painful because of __ build-up.

Answer 21

gas

Question 22

How is a gallstones diagnosis made?

Answer 22

Ultrasound

CT scan

MRCP / ERCP

Question 23

How are acute cholecystitis patients treated supportively?

Answer 23

Analgesia

IV antibiotics (for infection)

IV fluids

Nil by mouth

Question 24

How is acute cholecystitis treated curatively?

Answer 24

Cholecystectomy (ASAP)

Question 25

By what means are cholecystectomies carried out nowadays?

Answer 25

**Laparoscopically** i.e keyhole surgery

Question 26

What sign may be seen if a gallstone obstructs the common bile duct?

Answer 26

**Jaundice**

Question 27

What inflammatory disease is caused by the obstruction of the common bile duct by a gallstone?

Answer 27

**Cholangitis**

Question 28

If a gallstone blocks the CBD and the Sphincter of Oddi is closed, where can bile be redirected? What does this cause?

Answer 28

**Pancreas** **Acute pancreatitis**

Question 29

What investigation can also be used to remove gallstones from the common bile duct?

Answer 29

**ERCP**

Question 30

What are the two main causes of **acute pancreatitis?**

Answer 30

**Gallstones** **Alcohol** (GET SMASHED)

Question 31

What occurs to cause the damage seen in **acute pancreatitis**?

Answer 31

**Pancreatic tissue is digested by its own enzymes**

Question 32

How is **acute pancreatitis** caused by gallstones treated?

Answer 32

**Cholecystectomy** in fit patients **ERCP** if frail

Question 33

What is **gallstone ileus**?

Answer 33

**Small bowel obstruction** caused by a gallstone lodging in the distal ileum

Question 34

How can a gallstone reach the distal ileum in gallstone ileus?

Answer 34

**Fistula between gallbladder and duodenum**

Question 35

The movement of a gallstone through the small intestine in **gallstone ileus** causes ___ pain.

Answer 35

**colicky**

Question 36

What will patients present with in gallstone ileus?

Answer 36

**Small bowel obstruction**

Question 37

How is **gallstone ileus** treated?

Answer 37

**Laparotomy** (opening of abdomen) ## Footnote **Removal of gallstone surgically**

Question 38

What surgery will be carried out 3 months after the treatment of a gallstone ileus?

Answer 38

**Cholecystectomy**

Question 39

What is the **gold standard** investigation for gallstones?

Answer 39

**Ultrasound**

Question 40

What is a malignant cancer of the biliary tract?

Answer 40

**Cholangiocarcinoma**

Question 41

What is the clinical presentation of **cholangiocarcinoma**?

Answer 41

**Jaundice** **Weight loss** **Anorexia** **Fatigue**

Question 42

Where does **cholangiocarcinoma** tend to metastasise?

Answer 42

**Lymph nodes** **Liver** **Peritoneum**

Question 43

What investigations are used to diagnose and stage cholangiocarcinoma?

Answer 43

**Ultrasound** **CT** **ERCP** **MRI**

Question 44

**Cholangiocarcinoma** tends to present **(early / late)**.

Answer 44

**late**

Question 45

Bismuth-Corlette stages for cholangiocarcinoma - higher stages = greater spread in biliary tract

Question 46

What is the only curative treatment for **cholangiocarcinoma**?

Answer 46

**Bile duct / liver resection**

Question 47

What treatment can be used to **palliate** symptoms caused by bile duct obstruction in cholangiocarcinoma?

Answer 47

**Stenting**